Surgical outcomes of total arch replacement with modified elephant trunk technique in type A aortic dissection: insights from single-center experience

Background Total arch replacement with modified elephant trunk technique plays an important role in treating acute type A aortic dissection in China. We aim to summarize the therapeutic effects of this procedure in our center over a 17-year period. Methods Consecutive patients treated at our hospital due to type A aortic dissection from January 2004 to January 2021 were studied. Relevant data of these patients undergoing total arch replacement with modified elephant trunk technique were collected and analyzed. Results A total of 589 patients were included with a mean age of 53.1 ± 12.2 years. The mean of cardiopulmonary bypass, cross-clamping, and selected cerebral perfusion time were 199.6 ± 41.9, 119.0 ± 27.2, and 25.1 ± 5.0 min, respectively. In-hospital death occurred in 46 patients. Multivariate analysis identified four significant risk factors for in-hospital mortality: preexisting renal hypoperfusion (OR 5.43; 95% CI 1.31 – 22.44; P = 0.020), cerebral malperfusion (OR 11.87; 95% CI 4.13 – 34.12; P < 0.001), visceral malperfusion (OR 4.27; 95% CI 1.01 – 18.14; P = 0.049), and cross-clamp time ≥ 130 min (OR 3.26; 95% CI 1.72 – 6.19; P < 0.001). The 5, 10, and 15 years survival rates were 86.4%, 82.6%, and 70.2%, respectively. Conclusions Total arch replacement with modified elephant trunk technique is an effective treatment for acute type A aortic dissection with satisfactory perioperative results. Patients with preexisting renal hypoperfusion, cerebral malperfusion, visceral malperfusion, and long cross-clamp time are at a higher risk of in-hospital death.

Retrieving a lost needle in the descending aorta during hemi-arch replacement

A 73-year-old man diagnosed with moderate aortic insufficiency and dilatation of the aortic root and ascending aorta underwent a modified Bentall procedure and hemi-arch aortic replacement. During open distal anastomosis of the ascending aorta, the surgical needle was lost. Because of circulatory arrest, the operation was continued; before closing the chest, radiography and a transesophageal echo were located in the needle in the descending aorta. It was retrieved using a snare catheter via the graft branch under fluoroscopic guidance. Thus, locating the needle in the descending aorta and leaving the graft branch uncut led to its removal without a new incision.

Neuroprotective strategies with circulatory arrest in open aortic surgery – A meta-analysis

Objective Deep hypothermic circulatory arrest (DHCA) in aortic surgery is associated with morbidity and mortality despite evolving strategies. With the advent of antegrade cerebral perfusion (ACP), moderate hypothermic circulatory arrest (MHCA) was reported to have better outcomes than DHCA. There is no standardised guideline or consensus regarding the hypothermic strategies to be employed in open aortic surgery. Meta-analysis was performed comparing DHCA with MHCA + ACP in patients having aortic surgery. Methods A systematic review of the literature was undertaken. Any studies with DHCA versus MHCA + ACP in aortic surgeries were selected according to specific inclusion criteria and analysed to generate summative data. Statistical analysis was performed using STATS Direct. The primary outcomes were hospital mortality and post-operative stroke. Secondary outcomes were cardiopulmonary bypass time (CPB), post-operative blood transfusion, length of ICU stay, respiratory complications, renal failure and length of hospital stay. Subgroup analysis of primary outcomes for Arch surgery alone was also performed. Results Fifteen studies were included with a total of 5869 patients. There was significantly reduced mortality (Pooled OR = +0.64, 95% CI = +0.49 to +0.83; p = 0.0006) and stroke rate (Pooled OR = +0.62, 95% CI = +0.49 to +0.79; p < 0.001) in the MHCA group. MHCA was associated significantly with shorter CPB times, shorter duration in ICU, less pulmonary complications, and reduced rates of sepsis. There was no statistical difference between the two groups in terms of circulatory arrest times, X-Clamp times, total operation duration, transfusion requirements, renal failure and post-op hospital stay. Conclusion MHCA + ACP are associated with significantly better post-operative outcomes compared with DHCA for both mortality and stroke and majority of the secondary outcomes.

Subcapsular hepatic hematoma as a complicating cardiac surgery

An 80-year-old woman was hospitalized for aortic valve insufficiency, paroxysmal atrial fibrillation, and ascending aortic aneurysm. She underwent aortic valve replacement, pulmonary vein isolation, left atrium appendectomy, and ascending aorta replacement. She developed a subcapsular hepatic hematoma during the surgery. The patient was managed conservatively and discharged successfully.

Coronavirus disease 2019-induced hypercoagulability and its clinical implications

Coronavirus disease 2019 is the disease produced by severe acute respiratory syndrome-coronavirus-2, which is introduced into the host’s cell thanks to the angiotensin-converting enzyme 2 receptor. Once there, it uses the cell’s machinery to multiply itself. In this process, it generates an immune response that stimulates the lymphocytes to produce cytokines and reactive oxygen species that begin to deteriorate the endothelial cell. Complement activation, through the complement attack complex and C5a, contributes to this endothelial damage. The different mediators further promote the expression of adhesion molecules on the endothelial surface, which encourages all blood cells to adhere to the endothelial surface to form small conglomerates, called clots, which obstruct the lumen of the small blood vessels. Furthermore, the mediators of clot lysis are inhibited. All this promotes a prothrombotic environment within the pulmonary capillaries that is reflected in the elevation of D-dimer. The only solution for this cascade of events seems to be the implementation of an effective anticoagulation protocol that early counteracts the changes induced by thrombi in the pulmonary circulation and reflected in the functioning of the right ventricle.

Performing cardiac surgery during COVID-19 pandemic in Surabaya, Indonesia: A single-center retrospective observational study

Background Healthcare workers are still the front liners in health care services, and have major roles during the COVID-19 pandemic. In a resource-limited country like Indonesia, it is necessary to provide safe screening and management both for patients and healthcare workers to minimize the transmission. We report our experience in the cardiac surgery department on how to provide safe management during the COVID-19 pandemic. Methods A retrospective observational study was performed in a single-tertiary-center cardiac surgery department in Surabaya and included all patients who underwent cardiac surgery during the first year of the COVID-19 pandemic. We also collected the patients from a 1-year period before the pandemic as the comparison data. Analysis of the patient characteristics, operative data, and postoperative outcome, was performed. This study also provides our experience in changes of admission in the cardiac surgery preoperative system that can be utilized for others. Results A total of 179 patients were admitted to and had cardiac surgery. Of these, 3.80% ( n = 7) were COVID-19 confirmed by a real-time polymerase chain reaction. Five patients were delayed to have cardiac surgery with no mortality or morbidity reported in these patients. During the period after changes of admission procedural in cardiac surgery patients, there were no healthcare workers infected by COVID-19 by patient transmission in our center (0%). Conclusion Our study reported a systematic screening and that possible delay in cardiac surgery appears to be feasible and safe, both for patients and for healthcare workers during the COVID-19 pandemic.

Effectiveness and safety of povidone iodine for prolonged lung air-leak after lung surgery

Background Pulmonary surgery is often associated with postoperative prolonged parenchymal air-leak. The purpose of this study was to determine efficacy and safety of povidone iodine as treatment of prolonged parenchymal air-leak following all-types of lung surgery. Methods This prospective trial was conducted from June 2019 to December 2020, and designed under PanAfrican Clinical Trials Registry requirements. Patients having prolonged parenchymal air-leak were randomly allocated to povidone iodine protocol (Group A) or surveillance without povidone iodine (Group B). We collected the number of povidone iodine injections required before bubbling stopped, total drainage period, tolerance after injection, complications and side-effects. Comparative study was performed to evaluate povidone iodine efficacy. Results Following randomization, Group A included 19 patients, and Group B 21. Both groups were comparable. The mean drainage period was 9.21 days in Group A (6–14 days) and 15.62 days in Group B (7–31 days) ( p = 0.001). The mean hospitalization period was 11.05 days in Group A (7–16 days) and 18.9 days in Group B (9–38 days) ( p < 0.0001). The mean follow-up period was 6.8 months (3–18 months). No deaths were noted in either groups. Four side-effects were reported in Group A (21%) and four serious complications were noticed in Group B (19%). No recurrences were reported in Group A versus one recurrence of homolateral pneumothorax in Group B (4.76%). Conclusions Povidone iodine is an effective and safe solution for pleurodesis. It is associated with a low complication rate that remains acceptable, and could be proposed as treatment of prolonged parenchymal air-leak after lung resections.

The effect of pulsatile versus non-pulsatile flow during cardiopulmonary bypass on cerebral oxygenation: A randomized trial

Background The present study aims to compare regional oxygen supply determined by Near-Infrared Spectroscopy in the course of pulsatile perfusion with non-pulsatile perfusion during cardiopulmonary bypass in patients undergoing valvular heart surgery. Methods In this prospective randomized single-blinded trial, we enrolled adult subjects aged 18–65 years scheduled for elective valvular heart repair/replacement surgery with non-stenotic carotid arteries, employing a consecutive sampling method. Eligible patients were then randomly assigned in a 1:1 ratio to pulsatile or non-pulsatile perfusion during aortic cross-clamp. The primary outcome was regional cerebral oxygenation monitored by Near-Infrared Spectroscopy in each group. Results Seventy patients were randomly assigned, and each group comprised 35 patients. Mean age was 46.8 and 46.5 years in pulsatile and non-pulsatile groups, respectively. There were no significant between-group differences in regional cerebral oxygen saturation at different time points of cardiopulmonary bypass ( p-value for analysis of variance repeated measures: 0.923 and 0.223 for left and right hemispheres, respectively). Moreover, no significant differences in regional cerebral oxygen saturation levels from baseline between pulsatile and non-pulsatile groups at all desired time points for the left ( p = 0.51) and right ( p = 0.22) hemispheres of the brain were detected. Conclusion Pulsatile perfusion during cardiopulmonary bypass does not offer superior regional cerebral oxygenation measured by Near-Infrared Spectroscopy than non-pulsatile perfusion during cardiopulmonary bypass. Nonetheless, the efficacy of pulsatile flow in the subgroup of patients in whom cerebral blood flow is impaired due to carotid artery stenosis needs to be explored and evaluated by this method in future studies.

Pneumatocele formation following COVID-19 pneumonia. Is there a role for surgical intervention?

COVID-19 mainly causes a lower respiratory tract illness, meaning there has been great interest in the chest and lung radiological findings seen during the course of the disease. Most of this interest has centred around the computed tomographic findings. Most commonly, computed tomographic images report ground-glass opacities but a less common finding, and potential complication associated with COVID-19, is pneumatocele formation. In this case series, we describe the presentation and management of three patients with large pneumatoceles that developed during the recovery phase of COVID-19. A conservative approach is most recommended, with surgical intervention reserved for complicated cases that cause cardiorespiratory compromise.